NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT RECEIPT
I have received the Notice of Privacy Practices on this visit or a previous one. I understand I can request another copy at any time.
PLEASE CHECK ALL THAT APPLY
I GIVE MY CONSENT TO THIS OFFICE TO RELEASE ANY AND ALL RESULTS TO THE PERSONS LISTED BELOW
I acknowledge that I have read and understand Health Smart Weight Loss & Gynecology L.L.C. Notice of Privacy Practices and consent to use or disclose of my protected health information by Health Smart Weight Loss & Gynecology L.L.C., for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills,to conduct health care operations of Health Smart Weight Loss & Gynecology and as required by law.
I also acknowledge that I understand my rights as a patient of this practice concerning my protected health information, as it is outlined in this notice. I am aware Heath Smart Weight Loss & Gynecology L.L.C., reserves the right to charge the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
This form does not constitute legal advice and is for educational purposes only. This form is based on current federal law and subject to change based on changes in federal law or subsequent interpretative guidance. This form is based on federal law and must be modified to reflect state laws where that state law is more stringent than the federal law or other state law exceptions apply.
600 Medical Drive,
Wentzville, MO 63385
Phone: (636) 333-1614
Fax: (636) 333-1615
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